CLUB MEMBERSHIP

CLUB MEMBERSHIP

for eligibility to participate in the "Adelaide to Port Lincoln Yacht Race" & "Lincoln Week Regatta"
Full Name:
MY DETAILS
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Your Mobile Phone Number:
E-mail:
Date of Birth:

MonthDayYear
Emergency Contact Name:
Emergency Contact Phone Number:
Australian Sailing Number - if you already have one:
MEDICAL CONDITIONS:
Special Club Membership $150.00

Payment Direct Credit Details:

Port Lincoln Yacht Club BSB No.: 633 000 Account No.: 150 202 505

Ref: please ensure that you provide your name as the reference for payment
Should be Empty: